AND MEDICAL TREATMENT AUTHORIZATION
(California Education Code Section 35330)
r In-state r Out-of-state
Completion of This Form is Required for ALL Field Trips/Excursions
Name of school:
I hereby give permission for my child, to participate in the
field trip/excursion as a part of his/her regular school program.
This field trip/excursion is to be held on ; or
From , 20 through , 20
Transportation for this field trip/excursion will be provided by
In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental or surgical diagnosis
or treatment and hospital care from a licensed physician as deemed necessary for the safety and welfare of my child. It is
understood that the resulting expenses will be the responsibility of the participant(s) parent(s)/guardian(s).
Note regarding administration of medication: If your child is required to take medication prescribed by a physician during
the course of this field trip/excursion, and you wish school district personnel to assist your child in taking this medication,
please indicate by signing below. In addition, please state the type of medication and attach a written statement from the
child’s physician detailing the method, amount and time schedules by which such medication is to be taken.
Signature of Parent/Guardian:
If there is a special medical problem(s), kindly attach a description of the problem(s) to this sheet.
I fully understand that all participants are to abide by and accept all rules and requirements governing conduct during the field
trip/excursion. To the extent permitted by the Education Code, any participant determined to be in violation of behavior standards
will be sent home at their own or their parent's/guardian's expense.
California Education Code Section 35330 provides as follows:
"All persons making the field trip or excursion shall be deemed to have waived all claims against the District or the State of
California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion."
I understand that the District does not require the minor student to participate in the field trip/excursion and I make
this request voluntarily because I desire the minor student to participate in the field trip/excursion. I also understand
that, if I do not consent to the minor student's participation, the minor student will be involved in alternative
supervised activities, for which the minor student will receive full credit.
I have carefully read this authorization and fully understand its contents and voluntarily consent to its terms and
Signature of Parent/Guardian: Date:
If you have health insurance, please list:
Health Insurance Company Policy Number:
In the event of illness or accident, if different from above, please contact:
White—Field Trip/Excursion Supervisor Yellow—School/Facility Pink—Parent/Guardian